HOME HEALTH
CARE 101
Home Care Experience?
Home Care Myths!
• Where “old” therapist go to die
• Can’t do until you have 1-2 years in a clinic
• Only works with the patient until they can get out to clinic for real
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therapy
All home care patients are bed bound
No one does it full time
No equipment to do “cool” stuff
Not able to specialize
Agencies are run by nurses
No research /evidence-based practice in home care
The Whole Truth
• New Grads Welcomed!
• Many Therapists work in Home Care Full Time
• Many Therapists decide to have specialization in
Home Care
• Therapists play in integral role in the leadership
of home care agencies
• EBP is alive and well in Home Care
Home Care Agency Structure
• Certified
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Certified by Centers For Medicare & Medicaid (CMS)
• HMOs and Private Insurance
• Licensed
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Private Duty
• Hospital-Based
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Hospital Discharges Are Primary Focus
• Independent
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All Referral Sources
Hospitals
SNFs
Assisted Living
Physician Office
• For-Profit
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Profits To Owners/Shareholders
• Pays Taxes
• Not-For-Proft
“Surplus” Must Be Used Within The Organization; Related to Mission
• Tax Exempt
• Revenue Remains Important
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What Is ‘Certified’ Home Health Care?
• Billing Through Major Payers
• Medicare/Medicaid
• Private Insurance, HMOs
• Interdisciplinary Team
• Skilled Nursing
• Physical/Occupational/Speech Therapy
• Medical Social Work
• Registered Dietician
• Home Health Aide
Continuum Of Care
Hospital
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Skilled Nursing/Inpatient Rehab Facility
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Home Health Care
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Outpatient Services
• Case Example
• Total Knee Replacement Surgery
• Best Outcomes?
• Most Cost Effective?
• Bundled Payment
Patient Populations
• Pediatrics
• Early Intervention
• Providers Credentialed By New York State
• Preschool Age
• Adult
• Acute
• Skilled Services
• Short-Term/Restorative
• Improvement Anticipated
• Long-Term
• Personal Care Assistance Program
• Funded by Medicaid
• Maintain Health & Wellness
• Hospice
• Palliative Care For Terminally Ill
• Physical, Emotional, and Psychosocial Needs
• < 6 Months To Live
Typical Diagnoses
• Falls Prevention
• Orthopedics
• Joint Replacement Surgery
• Fractures
• Neurology
• Stroke
• Multiple Sclerosis
• Parkinson’s Disease
• Amyotrophic Lateral Sclerosis
• Cardiopulmonary
• Heart Failure
• Chronic Obstructive Pulmonary Disease
• General Medical
• Frail Elderly
• Extended Inpatient Care
• **Medical Management Skills
• Vital Sign Monitoring
• Wound Assessment
• Triage
What Defines “Home”?
• Patient’s Home
• Family Member’s Home
• Independent Living Facility
• Assisted Living Facility
• Group Home
What exactly is HOME?
• Private Home
• Mobile Home
• Assistive Living Facility
• Independent Living Facility
• Apartment
• Group Home
There’s No Place Like “Home”
Home Health Care
Who Qualifies?
• Conditions Of Participation (Federal)
• 484.18 Acceptance of Patients
• “Patients are accepted for treatment on the basis of a reasonable expectation that the patients medical, nursing
and social needs can be met adequately by the agency in the patient’s place of residence.”
• Medicare Benefit Manual
• Homebound
• Skilled Service
• Physician Order
• Direct Access is N/A…unfortunately
• Reasonable & Necessary
• Intermittent
• Acute Change in Condition
• Rehab Potential
• Maintenance Therapy
• Jimmo vs. Sebelius
• Unique/Individualized Care Plan
Payment
• Medicare: Prospective Payment System (PPS)
• Instituted in 2000
• Fixed payment for 60-Day Episode Of Care
• Case Severity Determines Payment
• Outcomes Assessment Information Set (OASIS)
• Therapy services
• **Home health services that meet the guidelines are covered by
Medicare at 100%.
• Medicaid
• Recent NYS Reductions
• Episodic Payment
• Managed Care
• Fee-For-Service
• Episodic Payment
Home Health Medicare PPS
• Base episode rate is $2137.73
• Responses to specific OASIS questions are organized into
3 domains:
• Clinical and Functional Severity
• Each Item Has A Severity-Based Point Value
• Service Utilization (Therapy)
• Greater Medical Complexity = More Reimbursement
Clinical Severity Domain
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Diagnoses
Parenteral/Enteral Nutrition or IV Infusion
Vision
Pain
Wound/Lesion
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Pressure Ulcer
Stasis Ulcer
Surgical Wound
Dyspnea
Urinary Incontinence
Bowel Ostomy
Behavioral
Clinical OASIS Question
Functional Status Domain
•Dressing upper body
•Dressing lower body
•Bathing
•Toileting
•Transferring
•Ambulation/Locomotion
•Ability To Self Manage Injectable
Medications
Functional OASIS Question
Service Domain
• Receipt of Therapy Visits
• Physical Therapy
• Occupational Therapy
• Speech Therapy
• Additional Reimbursement
• >/= 6 Combined Therapy Visits
• Medicare sees value in Therapy!
• Falls prevention
• Re-Hospitalization
• Functional Mobility
PPS Payment Variations...
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Low Utilization Payment Adjustment (LUPA)–
Four (4) visits or less are paid on a per visit basis
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Skilled Nursing $102
Physical Therapy $112
Occupational Therapy $113
Speech Language Pathology $122
Medical Social Work $165
Home Health Aide $47
• Typical Reason For A LUPA?
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Partial Episode Payment (PEP)
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Patient is admitted to Agency A, then elects to transfer to Agency B. Agency A
receives a proportional payment based on length of stay
Patient meets treatment goals, is discharged, then subsequently re-admitted
during same 60-day episode
Face-To-Face Encounter
• Direct Meeting Between Patient And
Physician/Non-Physician Practitioner
• Medicare Requirement
• 60 Days Prior To OR 30 Days Following Home Care
Admission
• Signed Attestation of Qualification For Home
Care Services
Home Care Clinical Outcomes
• Outcomes Assessment Information Set (OASIS)
• Centers for Medicare (CMS) system for measuring patient
outcomes
• Therapist can become certified specialist in OASIS:
• COS-C
• Clinical specialist
• HCS-D
• Coding specialist
Patient Satisfaction
• Consumer Assessment of
Healthcare Providers and
Systems (CAHPS)
• Medicare Home Care
Compare
Benefits of Home Care PT Practice: Case
Load
• 1:1 Patient Care
• 45min-1hr sessions
• 5-6 patients/day
• Changing work
environment
• Autonomy and flexible
schedule
Benefits of Home Care PT Practice:
Clinical Care
• Autonomous practice
• Ideal setting for
functional training
• Opportunity to fully
understand patient
perspective
• Interdisciplinary
collaboration
Vision 2020: six pillars
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Autonomy
Professionalism
Direct Access
The Doctor of Physical Therapy
Evidence-Based Practice
Practitioner of Choice
Specialization Of Services
• Advanced Training
• Diagnosis Specific
• Parkinson’s
• Stroke
• APTA Board Certification
• Multiple Areas of Specialization
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Geriatrics
Neurology
Orthopaedics
Cardiovascular & Pulmonary
Pediatrics
• 2,000 hours of clinical practice in the specialty area
The Challenges
Of
Home Health Care
Time Management
• Autonomous Practice
• Maximize Time With The Patient
• Organizational Skills
• Scheduling/Travel Route
• Flexibility With Scheduling
• Patients Sometime Unavailable
• MD Appointment
• Hospitalization
• Integrating Documentation Into The Visit
• How Good Is Your Memory?
• Exit Strategy
• Loquacious
Rural Home Health
• Distance Between Patients
• Windshield Time
• Proximity to Office
• Team Meetings/Ongoing Education
• Cell Phone Coverage
• Mentorship
Weather
Safety & Security
What Poses The Greatest Safety
Risk For Home Care Clinicians?
Safety & Security
• Pet Policy
• Needle Sticks
• Crime
• If Something Doesn’t Feel Right…
• Security Escort
• Off-Duty Police Officers
• Mandatory For ALL Staff
Variety Of Living Conditions
• Home Environment
• Family Support
• Abuse
• APTA Code Of Ethics
• 4D. Physical therapists shall report suspected cases of abuse involving children
or vulnerable adults to the appropriate authority, subject to law.
• Social Work
• Adult Protective Services (APS)
• Child Protective Services (CPS)
• Community Resources
Physical Therapy Assessment
in Home Care
• PMH and previous level
of functioning
• Gait
• ADL & IADL
• Cognitive/mental status
• Cardiopulmonary status
• (Vital Signs)
• Integumentary
• Neurological
• Musculoskeletal
• PROM
• AROM
• Strength
• Social
Support/Caregiver
Involvement
• Environmental/Home
Physical Therapy Assessment
in Home Care
Home & environmental assessment
• DME: Present, ordered, needed
• Living space: Functional & Quality of life
Home Safety Assessment
• Proper lighting
• Assess the appropriateness of a “Lifeline Alert System.”
• Safe stairway/hallway entrances
• Removal of throw rugs, cords
• Recommendation for bathroom grab bars, tub seat, other
DME
Physical Therapy Assessment
in Home Care
What are your home safety recommendations?
Physical Therapy Assessment
in Home Care
What are your home safety recommendations?
Physical Therapy Assessment
in Home Care
How do we meet our patient’s needs,
while still keeping staff safe?
Evidence Based Assessment
in Home Care
• Assessing Strength
• 5 Times Sit to Stand
• 30 Second Sit to Stand
• Assessing Upper Extremity Gross Function
• Functional Reach
• Assessing Cardiovascular Endurance
• 2 Minute Step Test
• 2, 4, 6 Minute Walk Test
• Assessing Agility
• 4 Square Test
Evidence Based Assessment
in Home Care
• Assessing Balance
• Berg Balance Scale
• Dynamic Gait Index
• Tinetti
• Assessing Cognition
• Mini-mental status exam
• Montreal Cognitive Assessment (MoCA)
• Assessing Functional Activities
• Barthel Index
Timed-Up-And-Go
Before & After
30-Second Chair Stand Test2,3,27
Measures
Endurance, Strength, Transfers
Purpose
Measure number of stands
completed in 30 seconds.
Time to Administer
30 seconds
Equipment Required
Chair and stopwatch
Norms
Age
Male (norm)
Female
(norm)
60-64
14-19
12-17
65-79
12-18
11-16
70-74
12-17
10-15
75-79
11-17
10-15
80-84
10-15
9-14
85-90
8-14
8-13
90-95
7-12
4-11
Two Minute Step Test
Measures
Muscular endurance, cardiovascular endurance,
balance and strength.
Purpose
Tests functional fitness in seniors.
Equipment needed
Stopwatch
Procedure
1.
2.
3.
4.
5.
Pre test vitals signs.
Mark midway between iliac crest and patella.
Have patient march for 2 minutes.
Knee must rise above marker.
Count the number of times the right knee rises above
the marker.
6. Post test vital signs.
Two Minute Step Test
Male Norms
Age
%
Rank
60-64
65-69
70-74
75-79
80-84
85-89
90-94
95%
135
139
133
135
126
114
112
75%
115
116
110
109
103
91
86
55%
104
104
98
95
90
78
72
35%
93
92
86
80
78
66
59
15%
79
77
71
63
62
50
42
5%
67
67
67
47
48
36
26
Jones CJ, Rikli RE. Measuring functional fitness of older adults. Journal on Active
Aging. 2002: 24-30
Two Minute Step Test:
Female Norms
Age
60-64
%
Rank
65-69
70-74
75-79
80-84
85-89
90-94
95%
130
133
125
123
113
106
92
75%
107
107
101
100
90
85
72
55%
94
93
87
87
78
73
61
35%
82
80
74
75
66
61
50
15%
66
63
58
59
51
47
36
5%
52
47
43
45
37
39
24
Jones CJ, Rikli RE. Measuring functional fitness of older adults. Journal on Active
Aging. 2002: 24-30
Physical Therapist’s Role
• What is the overall “plan” for the
patient, and how do your PT goals
help to meet the plan?
• Develop goals WITH the patient.
What were you able to do
a month ago that you would
like to be able to do again?
• Develop goals WITH the TEAM.
• Provide cost-effective care, while meeting the
functional needs of the patient.
Developing Goals
Who are the goals derived for?
Measurable
Function related
Achievable
Patient/caregiver
• Agreement
• Participation
Communication and Collaboration
The Clinical Team
Coordinator of Care
Physician and other
services
Patient, family, &
caregivers
Payers: managed care
Durable medical equipment (DME)
PT Intervention in Home Care
• Strengthening
• ROM/stretching
• Gait/Stair training
• Transfer/Bed Mobility
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Training
Balance training
DME training
Coordination &
proprioceptive training
Motor learning
Orthotic/Prosthetic
Training
• Modalities
• Moist and dry heat
• Ice
• Electrical Stimulation
• Ultrasound
• Wound Care
• Edema management
• Pain management
• Sensory retraining
• Breathing/respiratory
training
• Falls prevention/education
Discharge planning
Establish role and goals from day 1
Avoid learned helplessness
Link to patient goals
Other team members
Community resources
Continuum of care
Where Do We Discharge?
• Discharge with home exercise program
• Discharge with caregiver to assist
• Discharge to outpatient PT
• Discharge to day program
Technology
I Remember The Day….
Point Of Care
• 7” or 10” Samsung Galaxy Tablet
• 99% Electronic
• Documentation Efficiency
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Portability
Average In-Home Time= 43.2 minutes
Average Documentation Time After Visit= 11.7 minutes
Visits= 72% of documentation completed in-home
• Work-Life Balance
Virtual Meetings
• Multi-Branch Agencies
• Shared Education & Updates
• Common Goals
• ‘Connection’ To Team
Telehealth
Telehealth
• Telecommunications Technology For Remote Patient Monitoring
• Complex Medical Conditions
• Heart Failure, Uncontrolled HTN, COPD
• High Risk For Emergent Care or Re-Hospitalization
• Cost-Savings
• Quality of Care
• Monitors Blood Pressure, Pulse, Oxygen Saturation, Weight, And
Blood Glucose
• Data Analyzed By Registered Nurse
• Alert By Exception
• Coach Patient To Self Manage
• Alert Home Care Staff and Physician
Stretch Break
Diversity
Diversity is a collection of
individuals bringing together
varied demographic, cultural,
intellectual, and philosophical
differences.
Diversity
How do we differ?
• Age
• Gender
• Culture
• Sexuality
• Socioeconomics
• Education
• Physical abilities
• Religious beliefs
• Political beliefs
• Ideologies
Diversity
• We need to provide care that:
• Accepts, respects and understands that each individual has an
uniqueness that can be in the dimensions of race, ethnicity,
gender, sexual orientation, socio-economic status, age, physical
abilities, religious beliefs, political beliefs, or other ideologies.
Diversity: Education
• Health Literacy
• Average American reads at an 8th
grade level.
• 1/5 Americans are functionally
illiterate.
• 21% cannot read the front cover
of a newspaper
• People with low health literacy
utilize health care services more
often regardless of socioeconomic status
Diversity: Education
• Speak in lay terms
• Have your patient repeat or return
demonstration to ensure understanding
• Provide images with minimal written
instructions
• Don’t assume all patient’s have health
literacy
• Acknowledge the challenges of reading
medication instructions
Case Study #1
Linda Robinson is a 55 year old female you have been
seeing s/p BKA. Your plan is for her to continue with a HEP
after discharge. The Social Worker on the case has
informed you that the pt is functionally illiterate and quite
embarrassed by it.
What strategies would you utilize to provide the
comprehensive HEP she can complete properly, while
being sensitive to her reading level?
Diversity: Age & Generation
• Multi generational challenges
• What is a generation
• A group of people of the same age range who tend to hold shared
interest and attitudes. These shared values are the product of
witnessing historical and cultural events in one’s formative years.
• Communication Between Generations Video
Diversity: Age & Generation
• Traditionalist
• Born 1922-1943 (70-89 years old)
• World War II, Great Depression era
• Family members and gender roles, religion, rituals, and friends and
enemies clearly defined
• Intercultural relationships were almost non-existent
• Never jump the chain of
command
• Respect authority
• Limited exposure to technology
Diversity: Age & Generation
• Boomers
• Born between 1943 and 1965 (48-69 years
old)
• Raised in suburbia with many home
conveniences
• Most lived in two parent homes where mom
stayed home
• “Leave it to Beaver” values
• Can be demanding and self-motivated
Diversity: Age & Generation
• Gen- X
• Born between 1965 and 1977 (36•
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48 years old)
Raised in era of outstanding
technology
Schools became more integrated
Working mothers became the
norm
Computers were introduced in
schools
Diversity: Age & Generation
• Gen –Y
• Born between 1977 and 1999 (12-35 years old)
• Extensive knowledge of
technology
• Schools fully integrated and
students experiment with cross
cultural clothing, music, language
and relationships
• Because of multi-levels of activity they are
good time managers and multi-taskers
Case Study #2
You enter the home of 90 yo Jack McGuire for your
evaluation s/p a hospitalization for a CHF exacerbation.
He is confused when you introduce yourself as Doctor
stating, “I already have a doctor, plus you are too young
to be a doctor.” You notice pictures on his walls of
fighter planes from WWII and he goes on to tell you he
was a fighter pilot in the war and how much he hates
the “japs.” As you begin documenting on your tablet he
becomes irritated stating “Why are you wasting my
time?”
What strategies could you use to have a better
outcome?
Diversity: Language & Culture
• CLAS standards:
• Federal Guidelines
• 14 standards that call for National Standards for
Culturally and Linguistically Appropriate Services in
Health Care
• 4 Standards address Translation
• All Health Care providers who participate in
Medicare and Medicaid programs must incorporate
these standards
Diversity: Language & Culture
Using an Interpreter
• Be cautious if using family to Interpret
• Interpreter should stand next to you
• You should always speak to the patient, NOT the
interpreter.
• Speak slowly
• Avoid slang
• Avoid idioms
Diversity: Language and Culture
• Provide care that fits the culture
• Be willing to learn
• Learn to count, say hello, and thank you
• Ask about their customs
• Therapists must be able to abide by cultural
needs and Rules and Regulations mandated
by our health care system
Diversity: Language & Culture
Hispanic
• HCR Home Care Transcultural Nursing
• Overweight= sign of health/wealth
• Declining hospitality is viewed as disrespectful
• Outward signs of faith
should be acknowledged
• Family is very involved
• Respect for elders
• Proud and my not admit inability to understand
due to language barrier
Case Study #3
You arrive with an Interpreter to see Juanita Rodriguez for
balance training s/p multiple falls in the home. She is an
80 yo Spanish-speaking Puerto Rican woman who lives
with 3 generations of family. The extended family tends to
congregate in her home which made it difficult for the
patient to follow your instructions last time. The daughter
has offered you and the Interpreter tea and an empanada
when you enter. You have 45 minutes to complete your
session before your next appointment.
What actions will you take to provide culturally
competent care?
Diversity: Language & Culture
African American
• Tuskeegee Project
• Building a trusting
relationship is key
• Respect for elders
• Extended family and clergy are important especially in
times of illness
• Female head of household=competing priorities
Case Study #4
Elsa Johnson is a 50 year old morbidly obese (350#) woman who lives in a
2 bedroom apartment with her adult daughter and 3 grandchildren (ages
2,4,6). Her daughter works the C shift and sleeps during the day so Elsa
is responsible for watching the children. You are referred for a home
safety assessment, pressure ulcer prevention/education, and proper
equipment for pressure relief d/t pressure ulcers. The nurse is doing the
dressing changes. The patient already had to reschedule your evaluation
2x because the “children were out of control.” She lets you in the
apartment and says “lets make this fast.” You find the patient has no
pressure relieving equipment and the home has limited space for her
walker to navigate especially in the bedroom d/t many totes and trash
bags of clothing.
How can you do the meet the patient’s medical needs while
considering her cultural and socioeconomic?
Diversity: Language & Culture
Russian/Ukrainian
• Totalitarian societal background
• Notorious for non-compliance
d/t societies that place low
value on self-reliance
• Difficulty answering questions
about themselves directly
• Medical care is “crisis related”
• Limited focus on preventative
care
Diversity: Language & Culture
Russian/Ukrainian
• Family is typically told about terminal illness first
• Punctuality is important
• Removing shoes in the home is customary
• Guests are offered food, coffee or tea
Case Study #5
You are re-visting Alexandiy Vsyokovic for PD exacerbation. Your coworker completed the evaluation. He was a Physician when he lived in
Russia but retired and moved to the US to be close to his son. They live
in subsidized housing in a Russian/Ukranian neighborhood. You arrive
15 minutes late with the Interpreter. You enter the home and the pt’s wife
seems anxious and asks you to remove your shoes. Your companies
policy says you cannot walk in socks in a home. Upon questioning the
wife says (via the Interpreter) “His blood pressure was good yesterday so
I didn’t give him any medication, today it was up so I gave him an extra
dose of the lisinopril.” Your BP reading is 90/50. You ask how the HEP is
going since it was provided last visit. The patient and wife report he
hasn’t done the exercises and they would like you to come more often to
“give him exercise.” His insurance covers PT 2x/wk.
What are the cultural considerations and how would you address
them?
Diversity: Sexuality
Lesbian, Gay, Bisexual, Transgendered (LGBT)
• Gen Silent Trailer – YouTube
• Less likely to be partnered
• More likely to live alone
• Fear discrimination
• Don’t assume all people are
heterosexual
• Avoid using traditional role labels
Case Study #6
You are evaluating an 70 yo male patient in who has
moved into a handicap accessible senior living
facility after a fall with incomplete C4 SCI. You
arrive to the patient’s apartment to find the patient
in a power w/c. The medical record indicates he is
single and his emergency contact is Larry. The
patient’s goal is to return to his multi-story home.
How would you question to collect information
that is sensitive to his sexuality?
Diversity in Home Care
• HOME CARE IS CHALLENGING AND
REWARDING
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Generational diversity is only one factor in Home Care
Cultural diversity adds another layer to the puzzle
Therapist must be able to know customs and traditions
Therapists must be able to know traditional gender roles
Therapists must be able to abide by cultural needs and Rules
and Regulations mandated by our health care system
• All while being a guest in someone’s home
Why Should YOU Consider A Clinical
Affiliation In Home Health?
• 1:1 Time With Clinical Instructor
• Drive Time = Uninterrupted Mentorship
• Learn Diverse Set of Skills
• Interdisciplinary Collaboration
• Triage
• Medical Management
• Continuum of Care
• Autonomy
• Vision 2020
New Graduates
• Myth: New grads can’t work in home health
• Fact: NEW GRADS ARE WELCOME!
• NYS PT Practice Act
• Some states have restrictions
• Florida- PTs must have a minimum of 1 year experience
• MUST be the right fit!
• Student
• Home Care Agency
• Orientation & Mentorship
• Clinical Affiliation
Considering A Job In Home Health?
Entry-Level Employment
• What To Consider…
• Clinical Mentorship!
• Well-Developed New Hire Orientation
Program
• Growth Opportunity
• Ongoing Education
• Culture of Team Work and Support
• Employment Stability
Question, Answer
&
Feedback
Additional Resources
n National
Association Home Care (NAHC.org)
n Visiting Nurse Association of America (VNAA.org)
n Home Care Association of America (HCAA.org)
n Center for Medicare and Medicaid (CMS.gov)
n Home Health Section of APTA
(homehealthsection.org)
n State chapter of APTA, state home care
association
n Industry groups, publications, and list serves
Acknowledgments
Thanks to a number of individuals who have contributed over the years to the
development of this presentation.
• Chris Chimenti, PT, MS
Director of Therapeutic Services, HCR Home Care
• Jeanette Brown, PT, DPT, NCS, COS-C
Therapy Educator, HCR Home Care
• Tonya Miller, PT, DPT, COS-C
Eastern Regional Vice President, Celtic Healthcare
• Roger A. Herr, PT, MPA, COS-C
APTA Board of Directors